From the December 2015 issue of HealthCare Business News magazine
By Jill Rathbun
On Oct. 30, 2015, the Centers for Medicare & Medicaid Services (CMS) issued final rules updating payment policies, payment rates and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) and the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System for services performed on or after Jan. 1, 2016. There are several policies in the final rules that are of interest to the imaging community. Regarding the Medicare Physician Fee Schedule (PFS), one of the most anticipated policies was how CMS would take the next step regarding the implementation of the Appropriate Use Criteria program for the ordering of advanced medical imaging services.
CMS is implementing the first component of this program in this PFS final rule with comment period by establishing which organizations are eligible to develop or endorse appropriate use criteria (AUCs), the evidence-based requirements for AUC development and the process CMS will follow for qualifying provider-led entities.
A focus in the proposed rule was CMS’ definition of “provider-led entities” (PLEs), or those organizations that would be eligible to develop or endorse AUCs, because of the concern that radiology benefits management companies could get into the program. CMS proposed a definition as “including national professional medical specialty societies or an organization that is comprised primarily of providers and is actively engaged in the practice and delivery of healthcare (for example hospitals and health systems).”
However, in the final rule, CMS opted to apply a definition under which a PLE means “a national professional medical specialty society or other organization that is comprised primarily of providers or practitioners who, either within the organization or outside of the organization, predominantly provide direct patient care.” One of CMS’ rationales for this finalized definition is to allow the opportunity for third parties to collaborate with PLEs to develop AUC.
CMS is also modifying its proposal to require that the multidisciplinary team that a PLE uses for AUC development must include at least 7 members, including:
• At least one member with expertise in the clinical topic related to the criterion;
• At least one member with expertise in imaging studies related to the criterion; and
• At least one primary care physician representative.
The final rule also had CMS confirming that the agency will not finalize criteria for identification of qualified Clinical Decision Support (CDS) mechanisms, through which physicians would consult with applicable AUC, until after the end of the CY 2017 rule-making cycle. Therefore, CMS indicated that it will NOT require that ordering physicians consult with AUC during CY 2017, as required under the Protecting Access to Medicare Act (PAMA) of 2014. CMS suggested that it expects to have the initial list of CDS mechanisms available for review by summer 2017.
